From Moral Insanity to Psychopathy

Abstract

Psychopathy is currently a condition that arouses great interest among psychiatrists because of its significant involvement in the forensic field. The authors illustrate the course over time of the concept of psychopathy, starting from the definition of “moral insanity” of Prichard. The historical journey allows to illustrate the different positions that the various European schools of psychiatry have had toward psychopathy, until modern nosographic classification systems such as Diagnostic and Statistical Manual of Mental Disorders (DSM). Special attention is paid to the “core” of psychopathy: the alteration of the moral sense, and through the illustration of moral development is provided a reading of morality in the psychopath and the reasons for its impairment. A clinical and critical examination of psychopathy assessment scales is proposed, with the aim to broaden the horizons of assessment, also to individuals who do not show violent behavior, but with compromised moral sense. Lastly, authors propose an interpretation of the social aspects of psychopathy that goes beyond the assessment of the psychopath confined in jails, with several highlighted aspects of psychopathy that contribute to social success in work, relationships, and career and that can contribute to the success of the psychopath.

1. Introduction

The psychopathic syndrome is arguably one of the most dangerous and controversial constellations of personality traits, and has significant clinical and social importance. The syndrome of psychopathy has been described differently over time by a number of authors and scientific societies; despite these differences, all definitions of psychopathy highlight the impairment of the psychopath’s moral capacity. This chapter addresses the following key themes: psychopathology of morality, clinical features of psychopathy, psychopathy as a diagnostic entity, and social aspects of psychopathy.

2. Background

In the early 1800s, psychiatrists began to focus their attention on individuals who displayed particularly cruel and violent forms of behavior without suffering from any clear mental pathology.

In 1809, Pinel [1] introduced the term “partial insanity” or “mania without delusion” (manie sans délire) to denote a condition in which “no sensible alteration of the intellect, perception, judgment, imagination, or memory is observed, but there is a perversion of the affective functions, a blind impulse to violent acts…where it is not possible to identify any dominant idea or illusion of the imagination as a determining cause of this baleful trend.”

Esquirol [2] later labeled as “affective and impulsive monomania” alterations of the will that exist independently of any alteration of ideas, affecting individuals who “do not rave and ramble, whose ideas maintain their natural links, whose reasoning is logical, whose speech is not only coherent but often lively and witty, but whose actions are opposed to their affects, their interests and social custom. Their actions are irrational in the sense that they oppose their own habits and those of the people with whom they live. However disordered their actions, these monomaniacs always have more or less plausible reasons to justify themselves, so that one can say they are reasoning madmen.”

The term “moral insanity” was introduced by Prichard [3] to describe a “madness consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the interest or knowing and reasoning faculties, and particularly without any insane illusion or hallucinations.” “In cases of this description the moral and active principles of the mind are strangely perverted and depraved; the power of self‐government is lost or greatly impaired; and the individual is found to be incapable, not of talking or reasoning upon any subject proposed to him, for this he will often do with great shrewdness and volubility, but of conducting himself with decency and propriety in the business of life.”

Morel [4] defined “moral insanity” as “a delirium of feelings and actions with preservation of the intellectual faculties,” and he asserted the hereditary basis and degenerative nature of the affliction.

The psychiatrists of the time were not unanimous in the definition and description of the clinical picture, and a debate colored by the orientations of different schools of thought soon ensued and dragged on over time.

While there was a general consensus on the description of the clinical picture, two questions became the focus of attention and the site for clashes among different schools of thought.

1. Whether the clinical manifestation was acquired or congenital.

2. Whether it was an autonomous “psychopathological syndrome” or a manifestation/symptom of more complex psychopathological syndromes.

In Italy, there were diverse interpretive frameworks: some viewed moral insanity as “a form of madness distinct and independent from other forms” and others as “a simple variety or degree of common forms of madness.” Verga [5] distinguished moral insanity from monomania and defined both as “acquired frenzies.”

Levi [6] attributed a congenital character to moral insanity and argued for a differential diagnosis between monomania and moral insanity. He affirmed that monomania “compels the sufferer with a blind, automatic, and irresistible impulse—sometimes against the person’s conscience and will—to commit a given action, often a crime.” In moral insanity, on the other hand, “the person is led to commit immoral, wicked and cruel acts of all kinds, not as a result of a special instinctive impetus … but as a result of an actual paralysis of the moral sense, which renders the intellect blind to the ideas of good and evil and dull to the feelings of shame and remorse.” By contrast, Bini [7] maintained that moral insanity was not an autonomous pathological entity but a “variety” of other pathologies.

With regard to the congenital or acquired nature of moral insanity, the Italian school, in particular Tanzi [8] and Lombroso [9], tended to maintain that the clinical picture arose congenitally, and moral insanity came to be defined as a “constitutional anomaly.”

However, in the early twentieth century, moral insanity and monomania lost their status as diagnosable disorders and were merged into the psychopathological descriptions of other mental conditions.

Kraepelin’s contributions to psychiatry [10] constituted a milestone in the field: He moved away from the concept of single psychosis and instead identified two broad groups of mental pathology: dementia praecox and manic depressive psychosis.

He also linked the concept of mental illness to an organic basis: an underlying brain injury was the cause of the mental disorder.

Kraepelin moreover replaced Koch’s concept of “psychopathic inferiority” with the definition of “psychopathic states,” that is, conditions that affect individuals with certain distinctive personality traits. From that moment onward, the adjective “psychopathic” became associated with the noun “personality,” and the concept of psychopathic personalities started to gain ground.

Thus from the early 1900s, German psychiatry brought together under the heading of psychopathy the old French diagnosis of “moral insanity” and current personality disorders.

Arieti [11] described two distinct types of psychopaths:

• The simple psychopath, characterized by an epicurean lifestyle, poor introspective skills, aggressive behavior, the pursuit of privileges, and pursuit of the pleasure principle at the expense of the reality principle;

• The complex psychopath, distinguished by lack of impulsiveness, coldness of feeling, and the ability to manipulate and exploit others.

Later, the DSM would describe personality disorders, and in its different editions, it would adopt a variety of positions toward psychopathy.

However, the debate about whether psychopathy can constitute a diagnosis remains open to this day.

3. Psychopathology of morality

All definitions of psychopathy highlight the impairment of the psychopath’s moral capacity, and indeed the definition that preceded the concept of psychopathy was, for a long time, that of “moral insanity.” Thus, in order to understand psychopathy better, it is useful to delve more deeply into the development of the moral sense in individuals from childhood to adulthood.

Despite their diversity of opinions, researchers agree on two things: the first is that the development of morality takes place in successive stages, and the second is that the earliest years of life play a crucial role not only in personality formation, but also in social behavior. It follows that adult personality is an expression of characteristics developed during childhood also with regard to morality.

Piaget [12] was one of the first psychologists to focus on children’s morality. He tried to understand their concept of good and evil by analyzing children’s play. Observing the rules of children’s games and using interviews about such behaviors as stealing and lying, Piaget found that morality can be understood as a developmental process. Children’s earliest sense of morality is based on strict adherence to rules, duties, and obedience to authority: it is firmly linked to the conviction that a wrong action is automatically followed by punishment.

Subsequently, moral development is based on interaction with other children, and the discovery that strict adherence to rules can itself be problematic. Thus, a transition to a new stage becomes necessary. At this point, children develop a stage of autonomous moral thinking characterized by two elements: a critical and selective capacity to interpret rules, and an appreciation of mutual respect and cooperation. Piaget concluded that this autonomous morality, which takes into account the respect of others, is more solid and leads to more coherent behaviors than the moral sense of younger children.

Kohlberg [13, 14] later developed a theory of moral development that comprises six stages (Table 1).

Stage	Behavior
Premorality
Stage 1—Punishment and obedience orientation	Obedience to rules with the aim of avoiding punishment (similar to Piaget’s first stage)
Stage 2—Individualism and exchange	Adjustment to rules in order to gain rewards or benefits
Conventional morality
Stage 3—Morality as a means to maintain good relations with others and win their approval	Compliance with rules in order to maintain good relations with others and avoid their disapproval
Stage 4—Maintenance of the social order	Compliance with rules in order to avoid censure from the authorities
Morality as acceptance of moral principles
Stage 5—Morality of the social contract, individual rights, and widely accepted and shared laws	Desire to maintain a properly functioning society (although the question of what constitutes a “good” society is first raised at this point)
Stage 6—Universal principles	Morality based on individual principles of conscience
	Individual’s compliance with his or her own principles in order to avoid contrition

Table 1.

Kohlberg’s theory of moral development.

Kohlberg’s theory maintains that during childhood, conduct is governed by the first two developmental stages, in which morality is conditioned by punishment and obedience, as well as individualism and exchange.

Later moral stages are reached through a process of social learning that is conditioned, among other things, by the environment surrounding the individual’s everyday life. The moral criteria that are thus acquired from the familial and social context will continue into adulthood.

The highest level of moral reasoning, defined as post‐conventional, is the level at which the individual follows universal ethical principles that may not necessarily be in accord with the law, but which answer to the individual’s own conscience.

Further studies carried out in the 1970s brought a critical contribution to Kohlberg’s theory of moral development. In particular, it is fruitful to recall the contributions of Turiel [15] and Gilligan [16].

Turiel’s studies led to the formulation of domain theory.

This theory holds that children as young as 39 months of age already have two different conceptual domains that regulate morality: one domain is of external origin, namely social conventions, while the other has an intrinsic origin and corresponds to moral imperatives. The two domains have different effects, so that transgressing conventions is considered less serious than disobeying universally recognized moral norms.

On the other hand, Gilligan has developed a concept of great contemporary relevance, namely the idea that morality consists in care rather than justice or rights. There is thus a sort of moral obligation to solidarity rather than an obligation not to wrong others.

With regard to psychopaths, Kohlberg [13] was the first to find that young people with antisocial behavior displayed pre‐conventional moral reasoning, which suggests that there has been an arrest in moral development, influenced in part by negative life experiences.

Later, Campagna and Harter [17] used interviews based on Kohlberg’s method to examine the differences in moral reasoning that distinguished a group of young psychopaths from a control group.

The study revealed that psychopaths exhibited a lower level of moral reasoning than the control group of the same mental age. Among psychopaths, moral reasoning was predominantly at the pre‐conventional stage, whereas the control group followed conventional modes of moral reasoning appropriate to their age. The members of the control group displayed types of moral reasoning that went beyond individual needs to take into account the social context and shared norms. The moral reasoning of psychopaths was instead rooted in an egocentric position focused on the individual’s own needs and the balance between anticipated gain and risks incurred by their actions.

Other studies have confirmed that psychopaths exhibit a level of moral reasoning similar to that of children under the age of 10, falling under the pre‐conventional stage in Kohlberg’s scale [17–23].

At this point, the question that arises is: why do psychopaths display levels of moral reasoning lower than those of normal subjects? Are environmental influences and negative life experiences sufficient to account for this arrest in moral development?

Kohlberg’s hypothesis on the development of moral reasoning also takes into consideration the processes of cognitive development, postulating a parallelism between cognitive development and the development of moral reasoning. From this perspective, the maturation of complex cognitive structures is considered a necessary condition and a prerequisite for progressing through the various developmental stages of moral reasoning.

This hypothesis is buttressed by a study performed by Campagna and Harter [17], in which a group of psychopathic subjects and a control group were tested using the Wechsler Intelligence Scale for Children. The study showed that children who attained higher scores in cognitive intelligence also exhibited higher levels of moral reasoning.

This result lends credence to the hypothesis of a link between the cognitive system and its development, on the one hand, and the development of moral reasoning, on the other, such that impairment in the latter would be correlated with a deficient cognitive system.

According to the hypothesis, both systems would be impaired in psychopaths.

This hypothesis could constitute the key to interpret a number of cases of psychopathy that display both impairment of moral reasoning and cognitive deficits. However, actual clinical cases are more complex and nuanced: it is often possible to encounter psychopaths who display a good intellectual level of development, sometimes even higher than average, who employ their intelligence to achieve their personal goals through the manipulation of others.

Other authors have reported, through brain‐imaging studies, that the brains of psychopaths exhibit differences from those of normal subjects in the orbital cortex, which deals with ethical thought, moral choices, and impulse control [24]. Other researchers have found that the experience of violence as a source of pleasure or displeasure is associated with the functioning of the nucleus accumbens [25].

On the other hand, psychological theories have long emphasized that insecure attachment and trauma are closely linked with antisocial and violent behavior [26–28].

Meloy’s position [29] synthesizes the complexity of these arguments. He asserts: “My theoretical and clinical hypothesis is that psychopathy is psychobiologically predisposed, but there are necessarily deficient and conflictual primary object experiences that determine its phenotypic expression.”

Despite its theoretical appeal as well as its partial truth and clinical applicability, this position leaves unanswered the question that was initially posed back in the nineteenth century by the first scholars who described moral insanity and later psychopathy. Even after so much time has elapsed, it is still not easy to provide an exhaustive answer today, although there is a general consensus that psychopathy is an early onset pervasive personality disorder. Yet the question of how the various biological, psychological, and relational “etiologies” affect the “moral core” remains a mystery to be unraveled.

4. Clinical features of psychopathy

Many authors have described the clinical features of psychopathy, but Cleckley’s [30, 31] clinical description stands out among others and constitutes a milestone. In his book “The Mask of Sanity,” Cleckley sorts through observations from a wide range of cases in order to identify 16 specific traits that characterize psychopaths (Table 2).

1. Considerable superficial charm and average or above average intelligence

2. Absence of delusions and other signs of irrational thinking

3. Absence of anxiety or other “neurotic” symptoms. Considerable poise, calmness, and verbal facility

4. Unreliability, disregard for obligations, no sense of responsibility, in matters of little and great import

5. Untruthfulness and insincerity

6. Antisocial behavior which is inadequately motivated and poorly planned, seeming to stem from an inexplicable impulsiveness

7. Inadequately motivated antisocial behavior

8. Poor judgment and failure to learn from experience

9. Pathological egocentricity. Total self‐centeredness and an incapacity for real love and attachment

10. General poverty of deep and lasting emotions

11. Lack of any true insight; inability to see oneself as others do

12. Ingratitude for any special considerations, kindness, and trust

13. Fantastic and objectionable behavior, after drinking and sometimes even when not drinking. Vulgarity, rudeness, quick mood shifts, pranks for facile entertainment

14. No history of genuine suicide attempts

15. An impersonal, trivial, and poorly integrated sex life

16. Failure to have a life plan and to live in an ordered way (unless it is for destructive purposes or a sham)

Table 2.

Hervey Cleckley’s list of psychopathy symptoms.

The clinical features of these patients can be traced back not only to their behavior, but also to the style of their interpersonal relationships and their affective lives. These 16 traits highlight the absence of any psychopathological alterations; indeed, Cleckley describes psychopaths as endowed with charm and intelligence, not suffering from delusions or irrational thinking, without “nervousness” or psychoneurotic symptoms (traits 1–3). Instead, the list underlines aspects, such as the subjects’ ability to present a false representation of reality (traits 4 and 5), and peculiarities of their affective life, such as lack of remorse or shame, the inability to learn from experience, egocentricity and the inability to love, a significant poverty in major emotional reactions, and callousness in interpersonal relationships (traits 6, 8, 9, 10, and 12). There are also purely behavioral aspects such as the lack of adequate motivation for antisocial behavior, the display of bizarre behaviors, promiscuous and impersonal sexual behavior, and the inability to take up a life project (traits 7, 12, 13, and 16). The whole is accompanied by a distinctive lack of insight (trait 11).

Hare [32, 33] later developed the Psychopathy Checklist (PCL) (Table 3) as a tool for clinical evaluation of an individual’s degree of psychopathy through the use of a semi‐structured interview along with information obtained from the individual, his or her family members, and police reports.

1. Glibness/superficial charm

2. Grandiose sense of self‐worth

3. Need for stimulation/proneness to boredom

4. Pathological lying

5. Cunning/manipulative

6. Lack of remorse or guilt

7. Shallow affect

8. Callousness/lack of empathy

9. Parasitic lifestyle

10. Poor behavioral controls

11. Promiscuous sexual behavior

12. Early behavior problems

13. Lack of realistic long‐term goals

14. Impulsivity

15. Irresponsibility

16. Failure to accept responsibility for own actions

17. Many short‐term marital relationships

18. Juvenile delinquency

19. Revocation of conditional release

20. Criminal versatility

Table 3.

Hare’s psychopathy checklist.

The PCL‐R consists of 20 items that fall into two main groups:

• The first, referred to as factor 1 and labeled as affective/interpersonal deficit, describes a subject with inflated self‐esteem, selfish, without remorse, and exploitative of others;

• The second, known as factor 2, identifies an antisocial lifestyle characterized by impulsivity and irresponsibility.

In subsequent studies, based on the analysis of latent variables [34], Hare supported the four‐factor PCL‐R model. This model measures four dimensions of psychopathy that are strongly interrelated: interpersonal, affective, lifestyle, and antisocial. Factor 1 scores the individual’s interpersonal dimension and comprises four items (glibness, grandiose sense of self‐worth, pathological lying, and manipulation). Factor 2 scores emotional responses and quality of relations with others and comprises four items (lack of remorse or guilt, shallow affect, lack of empathy, and failure to accept responsibility). Factor 3 refers to the individual’s lifestyle and comprises five items (need for constant stimulation/proneness to boredom, parasitic lifestyle, lack of realistic goals, impulsivity, and irresponsibility). Factor 4 measures antisocial behaviors and has five items (poor behavior controls, early behavior problems, juvenile delinquency, revocation of conditional release, and criminal versatility).

Meloy [29] stresses that the main characteristics of psychopaths relate to their affective lives, which lack emotional ties, key reference figures, and emotional involvement in actions. Thus, psychopaths are able to commit the most cruel and brutal acts without hesitation, with emotional coldness, and without concern for the consequences that might befall them or their victims. The psychopath is a “lone wolf” who, unlike the antisocial individual, does not adhere to criminal subcultures, since the psychopath is unable to establish personal ties or follow rules, be they the rules of society or of a criminal underworld.

Another distinctive aspect of psychopaths is their capacity for seduction. Hare has drawn attention to this aspect in his description of the typical conversation with a psychopath, which is often rich in details, half‐truths, fragments of speech, and internal contradictions. It is not a type of conversation from which useful information can be gained, but it is rather marked by the psychopath’s deployment of charm, seduction, and manipulation.

Through their allure, seductiveness, and clever use of lying, psychopaths are expert manipulators of those around them.

Psychopaths may in fact be defined as “intra‐species predators who use charm, manipulation, violence, intimidation, and a constant violation of other’s rights in order to control them and satisfy their own egoistical needs” [35, 36].

Hare divided psychopathy into three different categories:

1. “Primary” or “true” psychopaths. These individuals are not characterized by violence and/or destructiveness. Rather, they are characterized by sociality, glibness, and charm. They are apparently normal, calm, and collected. The crux of psychopathy in their case consists in their being unable to feel any emotion, and in their extraordinary ability to manipulate and seduce. They are extremely skilled individuals, so much so that they rarely get caught by the criminal justice system and, when they do, they often fare well thanks to their manipulation skills.

2. The second category is that of “secondary” or “neurotic” psychopaths. These individuals display particularly cruel and heinous violent behavior without feelings of guilt or remorse. They have difficulty managing their emotions and are often impulsive. They often commit crimes, and often get arrested.

3. Hare’s third category is that of “dyssocial” psychopaths. These individuals are driven to acts that deviate from the social environment to which they belong, following dysfunctional models learned from significant figures in their lives. They differ from other psychopaths in that they have the capacity to experience guilt and to establish affective relationships. Hare claims that Bandura’s social learning theory could provide a key to understanding the behavior of dissocial psychopaths, explaining how their behavior stems from their culture and the society that surrounds them [37].

On the other hand, Millon and Davis [38] propose a classification of ten types of psychopathy based on character traits, behavioral aspects, and defence mechanisms. Their classification was partly taken up in the Psychodynamic Diagnostic Manual (PDM, 2006), which distinguishes between two subgroups of psychopaths: the first includes aggressive, explosive, predatory, and violent psychopaths, while the second comprises less aggressive individuals devoted to a parasitic and dependent lifestyle based on fraud.

From Cleckley onward, and subsequently with Hare, clinical descriptions of psychopathy have tended to approach it as a dimension involving a great variety of clinical manifestations.

However, certain limitations are worth noting.

PCL‐R has proved to be a useful tool for diagnosing psychopathy and for differentiating it from Antisocial Personality Disorder (ASPD).

The first limitation is inherent in this clinical scale and stems from its origin: PCL‐R, like Cleckley’s checklist before it, was developed from the observation of violent offenders; consequently, this scale reflects specifically those individuals but risks leaving out many false negatives: people who have not committed violent offences, yet are psychopaths insofar as their moral sense is deeply impaired and this affects their behavior and relationships. PCL‐R measures the maladaptive characteristics of psychopathy and would seem to be biased toward a specific subgroup of psychopaths, that is, violent ones. Consequently, a large number of psychopaths risk remaining unrecognized.

Moreover, although studies have shown a high level of interrater reliability, rater training may differ, leading to contradictory assessments [39].

The second limitation concerns another use of PCL‐R, which is to assess the risk of violence. PCL‐R is considered an important tool in violence risk assessment; specifically, it belongs to several actuarial tools for measuring the risk of violence, such as HCR‐20 (Historical Clinical and Risk Management) and VRAG (Violence Risk Appraisal Guide). However, a recent article has highlighted the limitations of violence risk assessment tools on account of the many false positives and false negatives which risk “distorting” treatment and social policy interventions, but especially because they are weak outcome indicators in terms of actual reduction in violence [40].

5. Psychopathy as a diagnostic entity

5.1. Psychopathy and the DSM

The construct of psychopathy has had a troubled, and at times controversial, relationship with the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM).

The DSM‐I [41] included a category termed “sociopathic personality disturbance,” one subcategory of which was “antisocial reaction.” These individuals were defined as “chronically antisocial,” and as profiting from neither experience nor punishment; they maintained no real loyalties to any person and were “frequently callous and hedonistic,” with a lack of any sense of responsibility. The definition included all cases previously classified as “constitutional psychopathic state” and “psychopathic personality.”

The DSM‐II [42] defined the “antisocial personality” using clinical criteria closer to Cleckley’s definition of psychopathy (Table 2), indicating that these persons were “grossly selfish, callous, irresponsible, impulsive, and unable to feel guilt or to learn from experience and punishment,” in addition to being drawn “repeatedly into conflict with society,” having low frustration tolerance and having a tendency to blame others for their problems. Based on this definition, a mere history of repeated legal or social offences was not sufficient to justify diagnosis. Despite its importance, Cleckley’s work did not propose a standardized method to evaluate or measure the clinical features identified, and thus remained confined to the field of pure theory.

A significant shift came about with the DSM‐III [43], whose major innovation consisted in the inclusion of specific and explicit criterion sets [44]. Feighner et al. [45] developed specific and explicit criterion sets for 14 mental disorders, and Antisocial Personality Disorder (ASPD) was the only personality disorder included. The inclusion of ASPD in Feighner et al. [45] was due largely to Robins’ [46] systematic study of “sociopathic” personality disorder, closely linked to Cleckley’s concept of psychopathy. Robins included a number of key Cleckley traits, such as lack of guilt, pathological lying, and the use of aliases (without including other items such as the lack of a sense of shame, the inability to accept blame, and to learn from experience, egocentricity, inadequate depth of feeling, and lack of insight). In addition, Robins’ list contained other nonspecific dysfunctions such as somatic complaints, suicide attempts or risk, drug use, and problems with alcohol consumption. Most of Robins’ items were accompanied by quite specific requirements for their assessment. For example, the determination of a poor marital history required “two or more divorces, marriage to wives with severe behaviour problems, repeated separations”; the category of repeated arrests was described as “three or more non‐traffic arrests”; and an assessment of impulsive behavior required “frequent moving from one city to another, more than one elopement, sudden army enlistments or unprovoked desertion of home” [46]. Robins’ 19‐item list [46] was reduced by Feighner et al. [45] to 9 items, including conduct disorder (required), along with poor work history, irresponsible parenting, unlawful behavior, relationship infidelity or instability, aggressiveness, financial irresponsibility, lack of regard for the truth, and recklessness [43].

New to the DSM‐III‐R criterion set was the item “lacks remorse,” obtained from the PCL and Cleckley, along with impulsivity or failure to plan ahead [47]. A related criticism of the DSM‐III criterion set was that it placed too much emphasis on a particular type of behavior, namely criminality [48]. “The DSM‐III criteria set may have selected too many criminals and excluded persons who were not criminal but who demonstrated the social irresponsibility, lack of guilt, disloyalty, lack of empathy, and exploitation central to most theories of psychopathy” [49]. However, the development of the DSM‐III coincided with the development of the Psychopathy Checklist (PCL) by Hare [32]. The PCL included Cleckley’s traits of superficial charm, lack of remorse, egocentricity, and lack of emotional depth, none of which were included in DSM‐III. On the other hand, the PCL did not include a number of the traits identified by Cleckley, for example, absence of delusions, good intelligence, fantastic behavior with drink, and suicide.

The DSM‐IV [50] took into consideration a revised version of the PCL, the PCL‐R, which included the deletion of two items (drug and alcohol abuse, and a prior diagnosis of psychopathy) and the broadening of the irresponsibility item to involve domains beyond simply parenting. The diagnostic criteria associated with ASPD in the DSM‐IV were related to the failure to conform to social norms, deceitfulness, impulsivity, irritability and aggressiveness, reckless disregard for safety of self or others, and consistent irresponsibility.

By the time of the DSM‐5 [51], there was considerably more research concerning psychopathy than ASPD [52]. The authors of the DSM‐5 referred to a new hybrid model of psychopathy developed concurrently with the DSM‐5: the triarchic model of psychopathy, assessed with the Triarchic Psychopathy Measure (TriPM), by Patrick et al. [53]. These authors identified three elements they considered essential to the understanding of psychopathy: boldness, meanness, and disinhibition. Further revisions made to the proposed criterion set for ASPD included three additional traits as potential specifiers for psychopathy: low anxiousness, low social withdrawal, and high attention‐seeking [51]. In any case, the proposed diagnostic criteria are not different from those of the DSM‐IV‐tr (Table 4).

A. There is a pervasive pattern of disregard for, and violation of, the rights of others, occurring since age 15, as indicated by three (or more) of the following:

Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest eceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure Impulsivity or failure to plan ahead Irritability and aggressiveness, as indicated by repeated physical fights or assaults Reckless disregard for the safety of self or others Consistent irresponsibility, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from others

B. The individual is at least 18 years of age

C. There is evidence of conduct disorder with onset before age 15

D. Antisocial behavior does not occur exclusively during a schizophrenic or manic episode

Table 4.

DSM‐5 criteria for antisocial personality disorder.

The psychopathic syndrome is probably one of the most dangerous and virulent constellations of personality traits, and it has significant clinical and social importance. The syndrome of psychopathy has been described differently by a number of authors and scientific societies [30–33, 41–43, 46, 47, 50–56]. There is “a lack of consensus regarding its conceptualization,” and it has been suggested that existing descriptions may be alternative constructions of the same hypothetical entity [48, 57]. The choice of which particular constellation to use in research or clinical practice is perhaps best made on the basis of which proves to be most useful for social or clinical purposes or, at best, which represents the consensus view within the field.

6. Social aspects of psychopathy

It is common to find dysfunctional psychopaths in prison, involved in more or less complex legal proceedings and caught up in scarcely enviable criminal careers. Indeed, many studies of psychopathy are born from the observation of incarcerated individuals. Cleckley studied a significant number of such individuals and made an important contribution to the clinical description of psychopathy. Nevertheless, the title that he gave to his work, “The Mask of Sanity,” suggests that we should observe psychopathy in a more articulated way.

It is likely that the social aspects of psychopathy, that is, the imprint that the condition leaves on an individual’s lifestyle and quality of life, are more complex and multifaceted than those we typically tend to observe.

Evaluation of the social aspects of psychopathy has long been affected by two gross biases: a limited observational perspective and the observer’s “countertransference” (understood in the broadest sense as the evaluator’s total set of emotional reactions).

With regard to the first bias, the observational perspective has often relied on incarcerated individuals; hence, what was observed was the dysfunctional effect of psychopathy on the lives of these individuals, whose lives were spent in prison or at any rate in the grip of the judicial system.

However, close observation of the real world would find numerous psychopaths whose lives have “benefited” from certain elements of psychopathy. Many successful psychopaths occupy prestigious positions in politics, finance, and entertainment.

Keeping in mind that the lack of morality is a constant element of psychopathy, it is useful to examine critically certain other elements of this condition and evaluate their positive or negative effect in terms of positioning the psychopath among either dysfunctional or successful individuals.

Dysfunctional elements notably include impulsivity, the recourse to violence, and poor judgment.

Impulsivity is dysfunctional because it is a very primordial element that leads to action without prior evaluation of consequences or of the situation’s complexity: impulsivity is no ally to developing tactics or strategies, or to social functioning.

The recourse to violence has always been associated with psychopathy. Numerous psychopaths are authors of particularly cruel and heinous violent acts. They are capable of committing such abhorrent acts because their feelings are anaesthetized, so they can act with coldness. Violent behavior is often committed as the result of impulsivity and without calculation of the consequences for the perpetrator or the victim. The use of violence is a dysfunctional element because it inevitably leads to the psychopath’s confrontation with the judicial system, leading to consequences such as imprisonment and the restriction of freedom.

The poor judgment displayed by psychopaths has led to their being considered cognitively deficient. Indeed, some psychopaths exhibit forms of intellectual impairment that have played an important role in the dysfunctionality that marks their lives.

On the other hand, the elements that play a role in the social success of some psychopaths include seductiveness, coldness of feeling, the role of empathy, emotional resilience, and the ability to manipulate others.

Even dysfunctional psychopaths display some charm and seductive abilities, albeit only superficially and in a relatively more recognizable manner. By contrast, charm and seductiveness are the signature traits of the successful psychopath. These individuals’ allure is complemented by a high and sometimes remarkable intelligence, which enables them to easily conquer their prey.

Indeed, these individuals’ charm relies on their capacity to manipulate others. Thanks to their loquacity, psychopaths can be extremely skillful manipulators who do not hesitate to deploy lies or half‐truths and present them as universal and irrefutable facts. They thus manage to make others see a partial view of reality and to persuade them in ways that ultimately lead to the psychopath’s own personal gain.

For a long time, the psychopath was described as an individual incapable of feeling empathy. This is only true in respect of a limited concept of empathy as the ability to understand the feelings of another or the ability to “put oneself in the other’s shoes.”

It is however necessary to “broaden” the concept of empathy in order to understand the psychopath. Studies on mirror neurons show that empathy also exists in the animal world [58, 59], and it is precisely the animal world that helps us better understand the psychopath. Thanks to a complex sensory system, animals are able to grasp when certain things are about to happen; for instance, an animal can understand that a predator is approaching, even without seeing the attacker, because it feels the latter’s presence through a set of “signs.” Some animals are also capable of sensing disruptive weather events, for example, the arrival of a thunderstorm, even before the appearance of any clear signal heralding the event. Psychopaths operate in a way that is very similar to the evolutionary system that gives animals protection. While it is true that psychopaths do not experience empathy in the sense that they are completely indifferent to the mood and suffering of others, it would be a grave mistake to think that they do not understand the emotions of others: in fact, psychopaths have an innate and extraordinary capacity to read and understand emotions, and to exploit them to their advantage.

Moreover, the psychopath has considerable emotional resilience. Resilience is a concept derived from physics that describes a material’s capacity to resist external traumatic force.

In psychology, resilience refers to the capacity to cope with traumatic events in a positive way. The psychopaths’ emotional resilience corresponds to their capacity to overcome any difficulties related to, or derived from, emotions in order to focus solely on their own personal gain. Thus, psychopaths allow neither the emotions of others nor their own to obstruct their path; they are deaf and blind to feelings and pay heed only to their own pleasure.

Emotional resilience in fact accounts for the low level of anxiety that is present in the successful psychopath. Anxiety, like fear, does not belong in the psychopath’s emotional makeup. Freedom from anxiety in turn facilitates the psychopath’s riskiest behaviors; not suffering from anxiety or fear, the psychopath tackles risk where normal individuals would be thwarted by fear. The ability to face risk, which resolves in a form of courage, gives the psychopath access to higher chances of success than would be possible for an individual with a timid or fearful attitude.

Additionally, the psychopath’s grandiose self‐esteem reinforces his courage and emotional resilience.

The successful psychopath also uses violence, but it is rarely the kind of brutal and heinous physical violence that would cause the perpetrator’s immediate identification, labeling, and exclusion. Instead, the successful psychopath is an extraordinary master of psychological violence, which he uses in the manipulation of others. The victim of psychological violence often does not recognize it as such because the psychopath’s charm and manipulative ability render it extremely difficult to identify his/her psychological aggressions.

The foregoing considerations, which spring from empirical, clinical observations, are confirmed by recent publications that highlight the positive aspects of psychopathy and suggest the possibility that these elements at times serve as sources of success in business, at work, and in relationships [60]. These considerations also suggest that certain aspects of psychopathy are more widespread in the general population than was thought, and are not confined to the prison population [61].

The other element that can lead to errors in the evaluation of psychopaths is “countertransference,” understood as a therapist’s full range of emotional reactions toward a patient. The therapist may deploy defence mechanisms such as identification with the victim, identification with the aggressor, projection, projective identification, etc., which often create obstacles to a correct diagnostic evaluation [62]. When dealing with psychopaths, the therapist’s perception may be further distorted by his/her moral judgment. Whether dysfunctional or successful, the psychopath exhibits moral impairment; often, in fact, the first observation that a therapist makes, even before further assessment, is that the individual appears to be amoral. This results in a counter‐transferential conditioning that prevents the evaluator from seeing the psychopath’s social success, and when social success is recognized, this recognition precludes detection of the individual’s psychopathic traits.

In conclusion, the conceptualization of psychopathy should move away from a vision of the psychopath as a sort of Hannibal Lecter. Though in some cases true, this vision is not the only applicable model; a different model that stands worlds apart but belongs also to the psychopathic dimension is that of a respected and successful head of government.

Psychopathy is increasingly understood as a spectrum disorder, with highly differentiated qualitative and quantitative expressions. This variability holds even for single traits so that, for example, one could have impulsivity at one end and the ability to act deliberately at the other, with widely different results along the spectrum.

Hence, the great dilemma that we sometimes grapple with in the face of an individual—mad or bad?—becomes more complex in the face of the psychopath—dysfunctional or successful?